Cancer Treatment Denied by Health Insurance: What to Do When “Medical Necessity” Becomes the Excuse
Being critically ill does not always mean that your health insurance company will be there for you when you need them to approve your claim for cancer treatment. The experienced Rancho Cucamonga insurance bad faith lawyers at Quincey Law can help you fight back when your claim has been wrongfully denied.
If the cancer treatment that your loved one needs is covered by the terms of your policy, the health insurance company cannot hide behind the excuse that it is not of “medical necessity.” Not only can you potentially force the insurance company to cover the care that you need, but you may also seek damages directly from them in a lawsuit if they have acted in bad faith. While the insurance company has power to an extent, it is sharply limited by the strict terms of California laws.
The Rancho Cucamonga insurance bad faith attorneys at Quincey Law passionately believe that health insurance policyholders deserve justice and a fair shake. Contact us today at (866) 945-9175 to learn how we can fight for you.
California Law Strictly Defines Medical Necessity
California law governs the standard that insurance companies must apply when they are determining whether coverage is medically necessary. Under the law, the term “medical necessity” means the following about your cancer treatment:
- Reasonable and necessary to protect life, prevent significant illness or disability, or alleviate severe pain
- Supported by generally accepted standards of medical practice
- Clinically appropriate in terms of type, frequency, extent, site, and duration
- Not primarily for the convenience of the patient or provider
According to the California regulations, cost alone is not a factor in determining medical necessity. The health insurance provider is allowed to consider lower-cost alternatives, but that may not be of help to you when there is a specific cancer treatment that you need. The health insurance provider may adopt an overly aggressive interpretation of the terms of the policy. Merely because something costs a lot of money does not give them an excuse to refuse to cover the care that you need.
The Affordable Care Act requires that the health insurance company give you a more specific explanation when they deny your care as not medically necessary. They must include a description of the criteria that they use to determine medical necessity. Once you have reviewed the explanation, you may be in a position to fight back if the denial of your care was wrongful.
How You Can Fight Back When Cancer Treatment Is Denied
You have various options to contest the denial of your cancer treatment. Your primary aim is to get the care that you need, but you can also seek justice when the insurance company has broken the law. Before you can take the insurance company to court, you may go through its internal appeals process first. If the insurance company continues to deny your claim, you may continue to exhaust your administrative remedies, which then means seeking an independent medical review. However, California law allows you to skip the independent medical review when there is bad faith involved in the denial. Further, you may be able to take your case directly to court if the matter is urgent, such as when you need vital cancer treatment.
You can file a bad-faith lawsuit against the insurance company when it has broken California law. When it comes to the denial of cancer treatments, it may be bad faith if the insurance company has done one of the following:
- Ignored the evidence provided by your treating oncologist
- Wrongfully referring to treatment as experimental when it should have been covered by the terms of your policy
- Denied your claim solely for purposes of reducing their own costs
- Failed to conduct a reasonable investigation before denying your claim
Health insurance companies have been held accountable in numerous lawsuits over the years when they have denied vital cancer treatment. For example, there were multiple lawsuits filed against a California health insurance company called Health Net (later bought by Centene) in the 1990s and early 2000s because it denied critical cancer coverage. One plaintiff won a jury verdict of nearly $90 million because the health insurance company refused to pay for an experimental bone marrow treatment when she was suffering from breast cancer. $77 million of the verdict was in the form of punitive damages for insurance bad faith.
Contact a Rancho Cucamonga Insurance Bad Faith Law Firm
Do not let the insurance company get away with denying the lifesaving care that you or a loved one critically needs. Take the first step towards firm legal action by scheduling a free initial consultation with a Rancho Cucamonga insurance bad faith attorney at Quincey Law. Speak to an experienced lawyer today by filling out an online contact form or by calling us at (866) 945-9175.
Nicholas Quincey is the founder of Quincey Law, and has over a decade of experience of handling insurance claims denials and personal injury matters for people throughout California. We have pursued insurance bad faith claims for people involving life insurance, health insurance, homeowners and disability insurance. We also work with clients and families who need assistance filing and pursuing a personal injury matter. Learn more here.